Suture tensioning device

ABSTRACT

A suture tensioning device is described that comprises first and second jaws in facing relationship and oriented in parallel to each other. The first and second jaws are disposed in relative slidable engagement so that one of the jaws is adapted for parallel movement towards and away from the other jaw to define a variable gap between them. A suture retainer is engaged with a surface of the second jaw to enable a suture to be tied so that the suture exerts a variable tension on the surface caused by the variable gap between the first and second parallel jaws. Preferably, the first jaw has defined therein a shape designed to engage with a surface from which a suture emanates. Methods for adjustably tensioning a suture and a kit for performing suspension of a tissue are described.

This is a continuation of copending application(s) Ser. No. 08/643,267filed on May 3, 1996, now pending, which application is a continuationof U.S. Ser. No. 08,314,244, filed Sep. 28, 1994, now abandoned.

BACKGROUND OF THE INVENTION

Stress incontinence is caused primarily by increased intra-abdominalpressure. One surgical method for treating this condition involvessuspension of the bladder neck for repositioning in the correct, fixedretropubic position so that there is no voiding of the bladder understress. Several relatively non-invasive surgical procedures for bladderneck suspension are described in Hadley et al., Urologic Clinics ofNorth America, Vol. 12, No. 2, p. 291 (1985).

In the original Pereyra method (West. J. Surg., 67: 223, 1959), a needleis passed from a suprapubic incision to an incision in the vagina nearthe bladder neck. Stainless steel suture wire is passed several timesfrom the bladder neck to the suprapubic incision to suspend the bladderneck. The Cobb-Radge method inserts the needle from below through thevaginal incision. The Stamey procedure (Ann. Surg., 192: 465, 1980) usesan endoscope to prevent the surgical needle from puncturing the bladder.Dacron vascular graft is used to anchor nylon suture in the periurethraltissue. Finally, in the Raz method (Urology, 17: 82, 1981) the surgeoninserts his or her finger through the vaginal incision to guide thesuspension needle and avoid penetration of the bladder by the needle.The sutures are anchored by threading through tissue of the vaginal walland tissue in the suprapubic area.

A major problem encountered during surgical needle suspension proceduressuch as described above is the correct positioning of the bladder neckand the urethra such that the position of the bladder neck with respectto the bladder is high enough to avoid incontinence under stress whilenot too high to prevent proper bladder voiding.

Over the years, various techniques have been developed using pubic bonefixation to suspend sutures. To facilitate the anchoring of thesuspending suture to the pubic bone with minimal soft tissue dissection,bone anchors with attached sutures are passed into a hole drilled in thepubic bone. Currently, a surgeon may place the tip of his or her indexfinger on the pubic bone anchor and tie down the suspending suture overhis or her index finger using the approximate dimension of the distalpulp of the index finger to deliver a certain degree of tension to thesuspending sutures. Once the finger is withdrawn, this leaves a smallmount of slack in the suture which permits a quasi-controlled andlimited suspension of the bladder neck when suspended in this way. Theslack is generally acceptable because of the large volume ofpubocervical fascia lending support to the bladder neck. It is, however,relatively easy to place excessive tension on the bladder neck. Chronicurine retention with endoscopic bladder neck suspension has beenreported in as many as 5 to 18.9 percent of patients. Excessive tensionwith overcorrection of the bladder neck is also known to account forbladder instability.

As an alternative to forming a suture sling by tying down against theindex finger, there is a need for a suture tensioner for providingconsistent, repeatable mounts of tension in the suture sling. Areproducible technique of tying the suspending suture is not presentlyavailable.

SUMMARY OF THE INVENTION

The present invention is a suture tensioning device that comprises firstand second jaws in facing relationship and oriented in parallel to eachother. One of the jaws is adapted for slidable and parallel movementtowards and away from the other jaw to define a variable gap between thetwo jaws. A support arm is connected to the first and second jaws and asuture retainer is engaged with the second jaw. Preferably, the firstjaw has defined therein a shape designed to engage with a surface fromwhich a suture emanates. A suture tied off using the suture retainerexerts a variable tension on the surface caused by the variable gapbetween the first and second parallel jaws.

A preferred device for variably tensioning a suture includes twoL-shaped support elements, each element having a shorter and a longerarm in orthogonal relationship. The longer arms of the respectivesupport elements are slidably engaged with each other and adapted formovement from a first position, wherein the shorter arms are inregistration and spaced apart from each other, to a second position,where the shorter arms are in registration and are closer together orfarther apart than at the first position, so that a variable gap betweenthe shorter arms is defined. A suture retainer is engaged with one ofthe shorter arms and adapted for tying off a suture emanating from asurface. A conforming element is engaged with the other arm. Theconforming element is adapted to mate with the surface so that thesuture can exert a variable tension on the surface and on any tissuesuspended from the surface by the suture. The variable tension is causedby the variable gap of the spaced-apart shorter arms.

A method for suspending a tissue from a surface includes the steps ofallowing free ends of suture material to emanate from the surface andthen providing a suture tensioning device to the surface. The deviceincludes first and second jaws in facing relationship and oriented inparallel to each other. One of the jaws is adapted for slidable andparallel movement towards and away from the other jaw to define avariable gap between the jaws. A first jaw of the device is thencontacted with the surface from which a tissue is to be suspended and afree end of suture material is engaged with (i.e., threaded through) thetissue to be suspended. The free ends of suture material are thencontacted with the second jaw and are then tied-off to each other usingthe second jaw. The tying-off distance from the surface and suspendedtissue is determined by the variable gap position between the first andsecond jaws of the device, so that the tissue is suspended from thesurface and the variable gap allows a variable tension to be imparted tothe suture material that is suspending the tissue.

A kit for performing suspension of a tissue can include, among othercomponents, the suture tensioning device of the invention; a suturepasser; a bone anchor, a drill and drill guide. The kit further includesa tray for carrying at least the bone anchor, suture passer andtensioning device of the invention. All components of the kit may besterilizable. In preferred kits, the bone anchor is pre-sterilized.

The use of the present suture tensioner can minimize post-operativeurinary blockage caused by excessive tension, and can minimizepost-operative urinary incontinence due to insufficient tension. Inaddition, the suture tensioner permits the visualization of suture knotsduring tying, thereby ensuring consistency of alignment of knot loops.The suture tensioner also permits consistent and reproducible tension tobe applied to a suture.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a schematic illustration of the suture tensioning device ofthe present invention deployed in use;

FIG. 2A-2B illustrates one embodiment of the suture tensioning device.

FIG. 2A is a frontal, partial cut-away view of one embodiment of thesuture tensioning device;

FIG. 2B is a cross-sectional view of one embodiment of the suturetensioning device;

FIG. 3 is an exploded view of another embodiment of the suturetensioning device.

FIG. 4 is a plan view of a second embodiment of the suture tensioningdevice of the invention, with the support elements shown in cut-awaycross-section.

DETAILED DESCRIPTION OF THE INVENTION

FIG. 1 schematically illustrates a suture tensioning device 10 of theinvention in place within the body. The device 10 includes a first jaw12 and second jaw 14 that are in facing relationship and are preferablyin registration so that the jaws 12, 14 are oriented parallel to eachother. Jaws 12, 14 are connected to at least one support arm 11. In FIG.1, each of the jaws 12, 14 are shown slidably engaged to the other byway of a single arm 11. It will be understood that two separate supportarms 11 may also be utilized. The first 12 and second jaws 14 can sliderelative to each other along the support arm 11 in the direction shownby the double headed arrows A. This may be accomplished by allowing jaw12 to be fixed and having jaw 14 slide. Conversely, jaw 14 may be fixedand jaw 12 may slide. Whatever slidable engagement is accomplished, thearrangement of the parallel jaws 12, 14 defines a variable gap 13between them when the jaws move towards and away from each other(hereinafter "to and fro" movement). In the preferred embodiments therespective jaws are parallel to each other. Nevertheless, those havingordinary skill in the art will readily appreciate that the either one orboth of the jaws may be hinged to allow for non-parallel orientation.

In FIG. 1, jaw 12 is disposed against a hard tissue 16 (i.e., a bone)into which has been emplaced in bone anchor 18. The bone anchor may beof any conventional design. A preferred bone anchor is described in U.S.Pat. No. 5,268,001 (Nicholson et at.), incorporated herein by reference.A particularly preferred bone anchor is that described in FIGS. 5 and 10of co-pending and commonly assigned U.S. patent application No.08/163,130, "Bone Fastener", filed Dec. 6, 1993, incorporated herein byreference. Briefly, this bone anchor is provided with a channel toreceive an intermediate portion of a suture (i.e., a segment between thefree ends) to form a so-called "slidable" suture element.

Referring again to FIG. 1, with a slidable bone anchor, a single suture20 is threaded onto the bone anchor 18. Alternately, a pair of separatesutures may emanate from bone anchor 18. A first free end 20A of thesuture is threaded through tissue 22 to be suspended and then the freeend 20A is engaged with the second jaw 14 of the device. The other freeend 20B of the suture that emanates from bone anchor 18 is engaged withsecond jaw 14 and knotted or otherwise affixed to the first free end20A. It will be appreciated that the variable gap 13 defined by thedistance between jaws 12, 14 will allow a surgeon to modify the tensionof the sutures 20 to suit the particular tissue(s) that are to besuspended. The distance that the tissue is suspended may vary althoughin the case of operations for stress urinary incontinence, thesuspension distance (i.e., the gap 13) ) may be several inches. Tissue16 does not necessarily have to be a bone (e.g., a pubic bone) but mayalso be soft tissue. Tissue 22 to be suspended may include the bladderneck or may just as conveniently be another tissue, for example theanterior cruciate ligament of the knee. When the present device 10 takesthe place of the distal end of the index finger, it allows reproducibletying of the suspending sutures, as described in more detail below.

A preferred embodiment of the invention is illustrated in FIGS. 2A and2B. The device includes a pair of L-shaped support elements 24, 25. Afirst support element 24 includes a first support arm 26 integral with,and in orthogonal relationship to, a shorter first contact arm 28.Contact arm 28 includes a distal face 29 and a proximal face 30. Theterm "distal" refers to that portion of the contact arm 28 closest tothe tissue to be suspended or from which sutures emanate. Similarly, thesecond support element 25 also includes a shorter, second contact arm 31integral with, and in orthogonal relationship to, a longer support arm32. The second contact arm 31 also has distal 34 and proximal 36 faces.

A suture retainer 38 is disposed upon the proximal face 30 of the firstcontact arm 28. Suture retainer 38 may include any number of sutureretaining configurations, such as a slit in the proximal face 30, agroove in the proximal face 30, a clip or wire engaged with the proximalface 30, and the like. The purpose of the suture retainer 38 is to holdthe sutures in place for convenient tying. In the most preferredembodiment, suture retainer 38 is a groove defined in the proximal face30 of the first contact arm 28.

Engaged with the second contact arm 31, most preferably on the distalface 34 thereof, is a conforming element 42 that is adapted to mate witha peripheral surface of the tissue or bone from which the suturesemanate. The conforming element 42 may include an elastomer disposed ondistal face 34 that conforms to the shape of the tissue or bone to whichit is mated. More preferably, however, the conforming element 42 is ashape defined in the distal face 34 that is designed to substantiallyconform to the shape of the tissue/bone interface that is to becontacted with the second contact arm 31. For example, if the device isused to suspend the bladder neck from the pubic bone, which has aslightly curved surface, the distal face 34 on the second contact arm 31will be designed and to have a slightly arcuate form in order to allowthe second contact arm 31 to engage and attain some purchase on thepubic bone.

The respective support arms 26, 32 in FIGS. 2A and 2B are preferably intelescoping relationship so that the outer diameter of support arm 26 issmaller than the inner diameter of support arm 32. Preferably, thesecond support arm 32 is hollow with a channel 23 defined in it intowhich the first support arm 26 is disposed in slidable engagement. Abias element 46, such as a spring or elastomeric material, is disposedin channel 23 within support arm 32 between the first 28 and second 31contact arms and is in simultaneous contact with each contact arm.Element 46 provides some resistance to the to and fro movement of theparallel, registered contact arms 28, 31.

In the most preferred embodiments, bias element 46 is calibrated so thatwhen the two contact arms 28, 31 are moved towards each other, it ispossible to know how much force is required. As a further aid indetermining the correct suture tension, a series of calibration marks 44may be formed on the outer peripheral surface 27 of support arm 26. Whenno bias pressure is applied to the contact arms, a portion of supportarm 26 extends out of the proximal end 21 of support arm 32. Thecalibration marks 44 on that portion of arm 26 will be visible to thesurgeon as an aid to correctly judge the exact tension on the suture. Asbiasing pressure is applied to force the contact arms together, thecalibration marks will be increasingly not visible as the support arm 26enters support arm 32. These marks and the bias element, in combinationwith the movable contact arms 28, 31, allows a surgeon to select aparticular tension on the sutures without having to rely on guesswork.In addition to providing a reproducible amount of tension in the tiedsuture, the use of the present device 10 spaces the knot of the sutureapart from the tissue during tying and allows visualization of the knotwhile it is being tied.

In another embodiment, to and fro movement of the parallel contact armsmay also be accomplished by providing second support arm 32 with achannel 23 defined in a peripheral surface thereof and by providingfirst support arm 26 with a dovetail 27 (see FIG. 3) or other similararrangement to mate with channel 23 which will also allow for slidableengagement of the support elements. Other configurations for allowingthe to and fro movement of the support elements, and thus to and fromovement of the parallel, registered contact arms, are readilyascertained by those of ordinary skill in the art.

In most preferred embodiments of the invention, as illustrated in FIG.4, a handle 58 is engaged with second support arm 32. The handle 58consists of a manually graspable gripping element 59 integral with atubular head 60. The second support arm 32 is engaged with handle 58 viathe head 60, or alternatively, by integral molding of the graspingelement 59, head 60 and second support arm 32 during manufacture. Thesecond support arm 32 may thus be fixed to the handle 58 and the angle(φ) subtended by the long axis B--B of support arms 26, 32 and element59 is generally about 90 degrees. Nevertheless, it will be understoodthat the attachment of the handle 58 to the support arms 32 may be amade using a pivoting attachment so that the angle subtended by thesupport elements and handle may vary considerably within a wide rangedepending on the circumstances of the surgery.

Illustrated in FIG. 4 is a stop 47 which is used to prevent further toand fro movement of the parallel contact arms once the appropriatesuture tension (i.e. gap width) is reached. In FIG. 4, the stop 47consists of a nut 48 connected to a threaded rod 50 that is engaged intoan aperture (not shown) in the outer peripheral surface 54 of secondsupport arm 32. The rod 50 then frictionally engages with an outerperipheral surface 56 of the first support arm 26, preventing the firstsupport arm 26 from further telescoping movement within the secondsupport arm 32. It will be appreciated that other mechanisms mayemployed to lock the first and second support arms to each other. Forexample, a ratchet, cam or other means that allows for releasablefrictional engagement of the first and second support arms may be used.The exact mechanism is not intended to limit the invention in any way.

The suture tensioning device 10, in particular the L-shaped supportelements, is preferably made of materials that are biocompatible. Theterm "biocompatible" means that the material is chemically andbiologically inert. Suitable materials must be rigid and include, forexample, stainless steel and P1700 polysulfone (Amoco Corporation). Thehandle 58, may also be made of these materials.

The sutures employed with the device are most preferably notbioabsorbable since the procedures most conveniently used with thepresent device are designed for long-term tissue suspension. The term"bioabsorbable" refers to those materials that are meant to bedecomposed or degraded by bodily fluids, such as, for example, blood andlymph. Exemplary sutures include Number 2 non-bioabsorbable,monofilament sutures (manufactured, for instance, by Davis and Geck,Co., Danbury, Conn.; manufactured under the tradename "Prolene" byEthicon, Corp. N.J.). If, however, circumstances permit use ofbioabsorbable sutures, known bioabsorbable polymers and copolymers rangein degradation time from about 3 months for polyglycolide to about 48months for polyglutamic-co-leucine. A common bioabsorbable polymer usedin absorbable sutures is poly (L-lactide) which has a degradation timeof about 12 to 18 months. Other polymers are derived from glycolic andlactic acids, such as a synthetic polyester chemically similar to othercommercially available glycolide and lactide copolymers. Glycolide andlactide degrade and absorb in the body by hydrolysis into lactic acidand glycolic acid which are then metabolized by the body.

The suture tensioning device of the invention may be fabricated using avariety of conventional methods. For example, a tensioning device madeof a biocompatible plastic is made by injection molding. Machiningprocedures are suitable for stainless steel devices.

There is no limit to the size of the device and the dimensions of thedevice will vary depending upon the surgical procedure and size of thesutures. Exemplary dimensions of a typical device of FIG. 4 include ahandle about 4.5" (114 mm) long. Arm 32 is about 1.5" (38 mm) long andarm 26 is about 1.25" (31 mm) long. The contact arms are each about0.25" (6.3 mm) long. Threaded rod 50 is about 1/8" (3 mm) in. length.

The invention also encompasses kits to be used by surgeons. Kits aretypically sold in supporting and packaging trays and all components ofthe kit, including the tray itself, are sterilizable using eitherautoclave or chemical sterilants such as, for example, ethylene oxide.Exemplary components of a preferred kit are made by Innovasive Devices®Inc., Hopkinton, Mass. 01748 and may comprise the suture tensioningdevice of the present invention, a speculum, a snare to pass the suturethrough the tissues (also called a "suture passer"), a bone anchor (SeeU.S. Pat. No. 5,268,001), a drill and a drill guide.

The suture tensioning device of the present invention may be used in anysurgical operation in which tissues are designed to be suspended, onefrom the other or are designed to be suspended from bone. As discussedabove, the most common use for the present device is in operations tocorrect stress urinary incontinence. Nevertheless, the device may bealso used in orthopedic surgical techniques, such as for example repairof the anterior cruciate ligament. Although many methods have beendeveloped to surgically correct stress urinary incontinence, thefollowing general description of the use of the present device in suchan operation is merely exemplary and is not intended to limit the scopeof the invention in any way.

Two separated, one inch transverse incisions are made over the pubicbone and dissection is carded down to the area of the rectus fascia.Beginning on the right side, the wound is stretched cephalad to allowthe vertical passage of a Stamey needle (Pilling Company, FortWashington, Pa.) through the rectus fascia. The needle is then sharplyangled onto the abdomen so that the point rests on the underside of thepubic periosteum.

The point of the needle, while maintaining contact with the underside ofthe pubis, is thereafter passed distally toward the introitus. At thecompletion of this distal passage, the needle can be palpated throughthe introitus to the right of the urethra. Palpation through the vaginais avoided during this distal passage of the needle to avoid pushing thebladder or urethra into the path of the needle. The tip of the needle iswithdrawn from the pubourethral ligament and gently swept along thepubocervical fascia to the area of the bladder neck under the guidanceof a finger within the vagina.

The needle is then passed through the pubocervical fascia and vaginalmucosa. A number 1 polypropylene suture is passed through the needlehole and withdrawn with the needle through the pubic wound. The needleis then reintroduced through the rectus fascia 2 cm lateral to theinitial passage and through the vaginal mucosa using the same needlepassage technique described above. The tip of the needle with thevaginal end of the suture is then withdrawn into the retropubic spaceand then advanced to a point where it is passed through the vaginalmucosa and passed distal to the introitus.

The suture is then removed from the needle and the needle tip once againwithdrawn to the retropubic space and passed through the vaginal mucosa.The vaginal end of the suture is then passed into the needle and pulledup through the pubic wound using the needle. The identical procedure isperformed on the left side. A 3.5 mm Innovasive® Devices, Inc. boneanchor (U.S. Pat. 5,268,001) is then used for pubic bone fixation of thesuspensory sutures. Two holes are drilled into the pubic boneapproximately 2 cm. lateral to the symphysis. One anchor for each side(2 per patient) is loaded with a medical suture end (which had lessvaginal contact than the lateral ends, thereby, potentially reducing thechance of bacterial contamination). Each anchor is placed into its holeand each anchor is disposed in place. See, for example, U.S. Pat. No.5,268,001, incorporated herein by reference. With the Innovasive®anchors, traction is not needed to assure adequate fixation of theanchors.

The sutures are then tied down with controlled tension so as to developa gentle elevation and cradle-like support of the bladder neck. Thesecond contact arm of the device is mated with the pubic bone in thevicinity of the bone anchors. The distance between the contact arms maybe varied at this point, although it is preferable to adjust thedistance between the contact arms prior to the operation. The free endof the sutures on each side of the bladder neck are threaded through thebladder neck and the other free end of the sutures is engaged with thefirst contact arm of the device. The free ends of the sutures are tiedtogether as in FIG. 1 in a controlled and reproducible manner.

To repair a cruciate ligament, one end of the ligament is fixed into thefemur. The other end of the ligament is threaded with sutures and ispulled through a hole in the tibia. The sutures are temporarily tiedusing the tensioning device of the present invention to tension theligament so that a range of motion can be performed, as a test for theligament tension. If the tension needs to be adjusted, the suture knotsmay be conveniently be tightened or slackened, if needed, using theadjustable arms of the device and the range of motion test performedagain. This is repeated until the surgeon is comfortable with theresults.

Equivalents

It should be understood that various changes and modifications of thepreferred embodiments may be made within the scope of the invention.Thus it is intended that all matter contained in the above descriptionbe interpreted in an illustrative and not limited sense.

We claim:
 1. A suture tensioning device, comprising:a support arm; afirst jaw attached to said support arm; a second jaw slidably attachedto said support arm in facing relationship with and oriented in parallelto said first jaw, so that said second jaw is adapted for slidable andparallel movement towards and away from said first jaw, said jawsdefining a variable gap therebetween; and a suture retainer on saidfirst or second jaw.
 2. The device of claim 1, wherein said sutureretainer is on said second jaw and said first jaw is shaped to conformto a surface from which a suture emanates.
 3. The device of claim 2,wherein said support arm comprises first and second support arms, saidfirst jaw is mounted on said first support arm in an orthogonalrelationship, and said second jaw is mounted on said second support armin an orthogonal relationship.
 4. The device of claim 3, wherein saidfirst and second support arms are telescopingly disposed relative toeach other to allow said first and second jaws to slide relative to eachother.
 5. The device of claim 4, wherein said first support arm has achannel defined therein and said second support arm includes a dovetailfor slidable engagement with said channel of said first support arm. 6.The device of claim 4, further comprising a biasing element disposedinside said first support arm and engaged with said second support arm.7. The device of claim 3, further comprising a stopper attached to thedevice in such a way that it is capable of being engaged with at leastone support arm for fixing a position of said first and second jawsrelative to each other without slidable movement.
 8. The device of claim7, further comprising a manually graspable handle attached to at leastsaid first support arm.
 9. The device of claim 8, wherein said handle isarranged at an angle relative to said first support arm.
 10. The deviceof claim 9, wherein said handle is adjustably mounted on said firstsupport arm so that said angle between said handle and said firstsupport arm may be varied.
 11. A kit for performing suspension of atissue, comprising:a suture tensioning device, comprising:a support arm;a first jaw attached substantially perpendicular to said support arm; asecond jaw slidably attached and substantially perpendicular to saidsupport arm in facing relationship with and oriented in parallel to saidfirst jaw, so that said second jaw is adapted for slidable and parallelmovement towards and away from said first jaw, said jaws defining avariable gap therebetween; and a suture retainer on said first or secondjaw; a suture passer; and a bone anchor.
 12. The kit of claim 11,further comprising a tray for supporting and packaging said bone anchor,suture passer and suture tensioning device.
 13. The kit of claim 12,wherein said suture tensioning device and suture passer aresterilizable.
 14. A suture tensioning device comprising:a first L-shapedmember comprising a first support arm attached substantiallyperpendicularly to a first jaw, said first support arm being hollow andhaving a channel therein; a second L-shaped member comprising a secondsupport arm attached substantially perpendicularly to a second jaw, saidsecond support arm being disposed in a slidable telescoping arrangementwithin said channel in said first support arm so that said first andsecond jaws extend from said telescoped support arms in substantiallyfacing parallel arrangement, and define a variable gap therebetween; anda suture retainer on said second jaw.
 15. The device of claim 14,further comprising a bias element disposed within said channel incontact with said second support arm at a point at which said secondsupport arm is attached to said second jaw, said bias element providingsome resistance against relative motion of said first and secondL-shaped members.
 16. The device of claim 15, wherein said bias elementis calibrated to indicate how much force is exerted when said L-shapedmembers are moved relative to each other.
 17. A suture tensioning devicecomprising:a first L-shaped member comprising a first support armattached substantially perpendicularly to a first jaw, said firstsupport arm being having a channel defined in a peripheral surfacethereof; a second L-shaped member comprising a second support armattached substantially perpendicularly to a second jaw, said secondsupport arm including a dovetail element, said dovetail element beingslidably engaged with said channel in said first support arm so thatsaid first and second jaws extend from said telescoped support arms insubstantially facing parallel arrangement, and define a variable gaptherebetween; and a suture retainer on said second jaw.
 18. A kit forperforming suspension of a tissue, comprising:a device for variablytensioning a suture, comprising:first and second L-shaped supportelements in sliding engagement with one another, said first L-shapedsupport element comprising:a first short arm; and a first long armattached to said first short arm in an orthogonal relationship, saidsecond L-shaped support element comprising: a second short arm; and asecond long arm attached to said second short arm in an orthogonalrelationship, said first and second L-shaped support elements beingarranged relative to one another so that said first and second shortarms are in registration with one another and define a gap of variablesize therebetween, said size of said gap being changeable by motion ofone of said L-shaped support elements relative to said other L-shapedsupport element; a conforming element on said first short arm, saidconforming element being shaped to matingly engage a surface from whicha suture emanates; and a suture retainer on said second short arm, saidsuture retainer adapted for tying off ends of said suture emanating fromsaid surface, said device being arranged and constructed so that saidtied-off suture exerts a tension of variable magnitude on said surface,said magnitude of said tension being determined by said size of said gapbetween said short arms; a suture passer; and a bone anchor.
 19. The kitof claim 18, further comprising a tray for supporting and packaging saidbone anchor, suture passer and suture tensioning device.
 20. The kit ofclaim 19, wherein the suture tensioning device and suture passer aresterilizable.